During this live webinar, Dr. Gupta will cover surgical and medical retina learning points from cases seen in the last 12 months. While supervising surgical residents during cataract phacoemulsification it occasionally becomes apparent that previous surgical habits do not quite work. Using video examples, we will review such cases and discuss techniques to help prevent a routine case becoming complex and ensuring a challenging case stays routine. Suggestions will be provided to make surgical flow better. In addition, a few learning points from medical retina cases will be discussed. The themes will add to the teaching suggestions in Dr. Gupta’s previous Cybersight webinars.
Lecturer: Dr. Rajen Gupta, Consultant Ophthalmologist, Newcastle Eye Centre, United Kingdom
[Rajen] Hello, everybody. It’s a real pleasure to be back giving a talk for Cybersight. My name is Rajen Gupta and I’m a consultant based up in Newcastle Eye Center based in Newcastle Upon Tyne in the UK. And I have a real interest in sharing my experience with performing cataract surgery. I’m also a medical retina consultant but I’ll be going through lots of tips that I’ve looked at over the last year that I’d like to share with you and at the end of the talk discuss a couple of medical retina cases as well. Some of the images are taken from my book but most of the things that I’m describing in the talk will be new. There are two previous talks that I’ve given for Cybersight, they are prerecorded and available for discussion and I’ll try and build on the concepts and the discussion that I gave in those talks today. And remember this talk is for you. I’m really happy for people to put in questions, I don’t mind what you ask, it doesn’t matter how small you think the question is or how complex, I’m happy to try and answer it for you. What I wanted to do in this third talk is really share some of the things that I’ve learned or I’ve taught other residents in the last 12 months. And I hope that you’ll be able to apply some of those concepts to your own surgery and hopefully promote it to make it much safer and more enjoyable, not only when you perform your own surgery, whether you’re teaching as well. During the talk I’m going to assume that you are supervising somebody else, that you are the trainer and you’re teaching somebody. What I’d like you to do is if you have some paper nearby, have it handy because I want you to try and write down some feedback points that you would give that person as if you were the supervisor. I’ve got a question for you. I have a 76-year-old patient who’s on tamsulosin, Flomax, known to give problems with pupils. They’re not diabetic, sorry, they are diabetic but there’s no diabetic retinopathy, and their overall visual acuity is 6/24. The surgeon that you’re supervising is quite experienced, they’ve done over 300 cases and they’ve come to you because they managed to get some time off and they said, “Look, can I do a couple of cases on your list? I don’t really need any supervision, I just want to get my numbers onto my logbook.” The question is, are you happy for them to operate? Or are you not happy for them to operate looking at this image? Often as a trainer, you have to make a decision on whether a case is suitable or not. We know that once you get past about 500 cases your complication rate drops. Which is excellent. During the first 40 and then the second 40 cases you may have a slightly higher complication rate then when you get more experience. So great. We’ve got roughly about 70% of people are saying, yep, absolutely. And I completely agree. Looking at the size of this pupil I would be happy for an experienced surgeon with 300 cases to operate. The final visual acuity for this patient is 6/7.5 and the patient ended up being very, very happy. And this is the kind of image from the end of the operation. What I haven’t shown you is what happens from the start of the operation all the way through to the end. This is what we’re going to go through by sharing the videos. And you can see that the images with the top right shows a nicely dilated pupil at the beginning. The surgeon has done a divide and conquer technique, but literally by the end of fragment disassembly and removal, the pupil has become very miosed. And that is something that probably could have been expected by the fact that the patient was on tamsulosin. We know that cases can become technically demanding and it’s up to the surgeon whether they allow that surgery to become more stressful, take longer, give rise to complications, and then become more and more challenging. And I call this a non active surgeon where the surgeon goes through the motions of operating but they’re not really thinking about how to make that surgery go from expert to proficient or proficient to easy peasy routine. Whereas the active surgeon will use their skills or if they’re being taught, have instruction to make it more fun and make it more routine. And especially to avoid complications. Thankfully for most cases, eyes will forgive the surgeon. Even if you’re not very active in making things easy, you’ll still get excellent vision. Whilst you’re watching the next few videos, I want to ask yourself what is the aim of the surgical step that the surgeon is performing? Then I want you to think of all of the positive points that are going on during the surgery because feedback is probably one of the most important things that you can do to promote good surgery and positive learning. If we focus on the negative then your confidence just simply goes down and then you start to worry and be scared of surgery. Think what was done well and then after you’ve done the things that have been done well, what would you suggest next time? Let’s go through this video. I’ll just let the video play through so that you can all watch it. The surgeon has done the rhexis, the hydrodissection, the divide and conquer, and now they’re removing the last couple of fragments. Often when we look at videos, you’re not performing the surgery yourself, it’s very easy to look at all of the things that are going wrong but you also need to think about what is going right. And with an experienced surgeon, they may not want to have lots and lots of instruction but rather they want to just get on with the operation and see if they can handle it. The question is, is whether they have the technical skill to get out of trouble? And we’re going to go through some of the tricks and aspects of this operation to make it easier the next time they do it. I’m sure we’ve all been in a situation where the pupil has become small and we’ve all been nervous as we operate. Okay, so hopefully on your piece of paper you’ve written down some good points. Let’s just go through those, first of all. What is the aim of the surgical step? The step at the moment is fragment removal. When I ask myself if I was assessing this person, I would say, did they manage to remove all of the lens material from the eye? And the answer is yes, they did. Great, I can tick that and say, “Well done.” Next, what did they do well? They manipulated the final fragment and rotated it into a better position. They removed the second instrument to create some space. They repositioned the microscope to try to keep it in the central position and despite the pupil miosis, they removed all of the lens material carefully. And they removed the phaco tip without that iris prolapsing through the main wound. Now if you look at the things you’ve written down and you have negative aspects, if you’re giving feedback, try and switch it around to what was done well first. If we were thinking about things that could be done better next time, we could think about teaching them about speculum insertion and draping, because you can see that the speculum fell out. The pupil was very small, and do they need to be taught how to deal with a small pupil and how to prevent the pupil from becoming smaller? The iris was floppy and we can see that it prolapsed through the side port. During the phacoemulsification, the mouth of the phaco tip was visible, suggesting that the energy could be directed towards the endothelium, which is not good if they have things like Fuch’s endothelial dystrophy or if they’re very elderly with a poor endothelial count. The position of the side port, was it ideal for divide and conquer? There’s lots of things that we can say to try and improve on. Let’s look at the next stage of the operation. This is soft lens material. And it doesn’t matter whether you use an automated irrigation/aspiration technique or whether you use bimanual. Both are absolutely fine. The question is, how do you use them and can you use them with good expertise to make sure that it does the job? Again, if we ask what was the task? The task was to remove the soft lens material. And this surgeon managed to do that very, very nicely. What could they do better next time? We saw that as the irrigation/aspiration probe was removed, the iris started to prolapse through the main wound. But quickly they were able to push it back using a little bit of viscoelastic. Next part of the operation. I want you to notice the injector tip and I’ll ask a question about the injector tip after this video plays. There are lots of things about inserting a lens inside the eye with a small pupil and the question is, how can the surgeon make it easier to get that instrument into the eye and avoid causing trauma? The good points in this are that the surgeon manages to get the lens through the pupil and removes the injector without any iris prolapsing. They use the second instrument to quickly dial that lens into the bag successfully. Now what did you notice about the injector nozzle? A. Was there some debris noted and was this makeup from the eyelashes? Was it debris and the viscoelastic was contaminated or do you think it was C, that the IOL cartridge was contaminated? Or are you not sure what that debris was on the tip? Or E, you know exactly where that came from. Sometimes when you look at things it doesn’t quite make sense. But hopefully you may have an idea what that debris was on the nozzle tip. Excellent, we’ll just get this. We have 13% of you think it may be makeup from lashes. You’re absolutely right. Sometimes you can get mascara or makeup on eyelashes. But usually you will notice that right at the beginning of the operation when you first start and you may get a very oily tear film or pigment in the tear film, which is easily washed off if you remove the cannula from a syringe and give the eye a good flush. Viscoelastic contamination. To get that kind of black pigmentation, is a thought and if that was the case you would hope that somebody would say, “Look, we need to change that viscoelastic.” Is it the cartridge? Absolutely. You could think it’s the cartridge and then 49% of you have said that you’re not sure what it is. And 9% of you say you know where it is exactly. It is actually E. It is debris from the first attempt the surgeon had at inserting the IOL into the eye. We can see that the eye is being pushed and as the nozzle goes in through the wound, the iris starts to prolapse. When you have a floppy iris, it is very easy for things to happen at any stage of the operation. And I must admit, when I was watching this I thought, “Oh, the lens has to go inside the eye absolutely fine,” and I stood up and walked away from the side arm of the microscope and then when I looked back I saw this picture. There are a couple of things that you can do here and the question is, is why did the iris prolapse during IOL insertion? And what happens is that when you are injecting, you push the plunger down with your thumb or whichever finger you use. But as the nozzle goes through the wound, if it doesn’t go in neatly and easily, you tend to release the pressure on the plunger. What happens is that the contents of the anterior chamber start to be sucked up into the nozzle. There what happened is that the iris was pulled into the injector. To try and avoid that, there’s a couple of things that you do. One is you maintain the pressure on the plunger so you don’t get that pulled effect. Secondly before you put the IOL into the eye, insert some extra viscoelastic near the iris to make that iris get pushed back as much as you can. And often what happens is that when you do that there is a small delay of 30 seconds or a minute as the IOL is prepared. By which time, a little bit of the viscoelastic can leak outside of the eye. If there is a delay between inserting viscoelastic and getting the IOL ready, put in a little bit more. Then finally, as the injector nozzle is inserted into the eye, the posterior lip of the wound is depressed. And by doing that, it allows the viscoelastic and the contents of the eye to try and escape and that’s what causes that iris to prolapse even further. We’re going to go through, in some slides later, how to deal with that prolapsed iris through the side port. I have another question for you. Having seen the video, even though the patient was very happy with the surgery and had excellent vision, are you A, happy with the surgery? Or are you B, oh sorry, A, not happy with the surgery, or are you B, happy with the surgery? Often I found that as a surgeon myself and operating, I often have a very high threshold for criticizing myself. And it’s much easier to be happy with somebody that you’re watching or not happy with them, but with yourself you could do a beautiful operation and still not be happy. The rhexis wasn’t perfect, the lens materials didn’t come out nicely, the iris didn’t behave in a nice way. And what I found over the years is that you have to be a little bit more forgiving, even on the people that you teach or on yourself. Let’s see what the audience think. That’s great. Only 29% of you are not happy. But 71% of you are, which is, I think, excellent. Remember the person doing the surgery is still learning. They are not an expert yet and beforehand they probably haven’t been told or shown how to deal with a floppy iris, iris prolapse, or a very small pupil. But I would be happy because the patient’s visual acuity was very good. As a trainer, I really want to avoid issues. And in the last 12 months I’ve seen a few little things that I wanted to share with you and you’ll see those in a moment. And I want to promote active teaching or active surgery that you can have fun and make everything routine and avoid complications. But if they occur, how can you then deal with them? This surgeon is a beginner. They haven’t done any whole cases. I’m teaching them fragment disassembly and fragment removal. Again, the patient is on tamsulosin and just before they remove the very last fragment I ask them to stop. I just want you to look at the video and gather your thoughts on what is happening and what you notice and whether you would be happy as either the surgeon or if you were supervising somebody. Just about now I stop the surgeon and say pause. There we go. I’ve stopped the surgeon. Let’s ask a question. Hopefully you’ve watched the video and you’ve got some ideas of what are happening inside the eye. If you were teaching somebody, remember this person now has not done a whole case. Would you A, you’ve noted that the iris is floppy and the last fragment is a little bit tricky and you think probably not safe, I should take over. Do you think that the PC has torn and the pupil is getting smaller because of that, so you need to take over? Do you think that the iris is floppy and when you look at the second instrument position it’s a problem and it needs to be repositioned? Do you think that the iris is peaked towards the main incision and the surgeon needs to remove the chopper and perhaps use some viscoelastic to deepen the AC? Or finally, hang on, everything looks to be going well, it’s okay, there’s no need to stop, carry on? Let’s see what the audience feel. Sometimes when you’re doing cataract surgery, there is no right or wrong answer. And only if you video your cases can you look at them later on and learn from them and learn from hindsight. The videos I’m going to show you now are hopefully going to be things and tricks to say how do you avoid a problem? How do you prevent something going from routine to technically demanding and complex? I want my junior trainee, who hasn’t done a whole cataract, they’ve done all the little bits, to be able to do that operation safely. 13% of you say it’s not safe and take over is needed. I think that’s absolutely fine. If you, as the trainer, don’t feel confident and you think for the patient’s safety it is needed, simply take over, it’s not a problem. There’s lots of cases that you can teach on. PC has torn. Now, if you get a PC tear, there is something called a snap sign and what happens is that the pupil initially dilates and then comes smaller again. But it doesn’t necessarily get smaller and smaller and smaller. In this case, we can see that the phaco probe is central, the pieces are coming quite easily, the pupil is still relatively round. At this moment I would say that there would be a PC tear. 18% of you said that the iris is floppy. Absolutely, we can see that the iris is billowing and moving all over the place. And that second instrument has been withdrawn. But if you look at it you can’t see the tip of the second instrument. That means that second instrument is pointing downwards towards the iris. 31 of you have said the iris is peaked towards the main incision. You’re absolutely right. The pupil is a little bit peaked towards that main iris. But we have the last fragment to remove. If we try and remove the second instrument and insert viscoelastic, it won’t really push that iris away and secondly, a beginner would find it probably very difficult to insert viscoelastic with their left hand whilst holding the phaco probe inside the eye. The trainer may have to do that. And finally, the fragment is going well, no need to stop. 17% of you. It’s actually the second instrument that is the problem here. Let’s have a little look at this and play it. The second instrument has been brought backwards, but because the tip is pointing down I didn’t like it. Because if the fragment is removed and then the second instrument withdrawn, the iris is much more likely to get caught. By turning it first, then removing the fragment, I know that that beginner can remove that second instrument very easily. The next thing is, I don’t want the iris to prolapse through the wound. And I’ve instructed the trainee to go very, very slowly when they remove the instrument. They paused near the main wound. And I’m going to show you that again. All the fragments are out but I’ve said just wait, slow down, and as you withdraw the phaco, turn it in a seven, just push it to the right and back to the center and don’t stroke the eye. And that way the irrigation pushes the iris backwards. Often people remove instruments far too quickly from the eye in a floppy iris, just like the video on the right with the iris prolapsing when the I/A tip was removed. It was just removed too quickly. Pause near the wound and then you won’t get that problem. The phaco is out, we have soft lens matter to remove. I’d like to ask another question. Which one of these would you not consider? And remember, this is a beginner. Would you suggest that they protect the side port with hydration? Should they be instructed to insert iris hooks or a Malyugin ring? Should you use a dispersive viscoelastic to push back the iris? Could you dilate the pupil more with intracameral phenylephrine? Or should we just use scissors, a sphincterotomy, to make the iris a little bit bigger to make it easier to remove the soft lens material? One of the things I’m very aware of is the cost of cataract surgery and the amount of disposables that we use and the wastage that is happening. And there is a mountain of wrapping and plastic that is associated with cataract surgery. We need to just make sure we use as little as possible. Protect the side port with hydration, 7%. Insert hooks or ring, 17%. Dispersive 24. And 13% phenylephrine and 40% of you may cut the iris with scissors. I think that’s an interesting concept. I think cutting the iris may be a little bit risky. Because you could cut the capsule at this stage, secondly it will cause trauma, and a lot more inflammation. Secondly we’re then teaching that person to deal with a small pupil by cutting the iris, which I really very, very rare. I don’t think I’ve ever cut the iris with a pair of scissors. It’s much either to either to use viscoelastic to push the iris back or use intracameral phenylephrine. And here we can see that initially they inserted a little bit of balanced salt solution and then they quickly inserted some phenylephrine at this stage, even though they used it at the beginning of the operation, because they were on Flomax. And we can see that the pupil dilates just a little bit bigger and then that will allow that beginner to carry on and remove that soft lens material and then put the lens in without me ever taking over. Just slow down the surgery and think, what can you do to make things easier? This is the learning point that I’ve learned in the last 12 months. The video is slightly dark and I’ll come back to that in a moment. Here we can see an irregular pupil and the pupil is moving towards the side port. But the second instrument is removed without any iris prolapse. And I’m going to show you that video again. The video is dark because my surgeon that I was supervising had turned off one light and had operated throughout the whole of the procedure with just one light on. Let me just share that video again for you. The idea is that we use the phaco probe to go over the iris and you sweep across and that pushes the iris down slightly so that when you remove the second instrument you don’t get any iris prolapse. It’s a very, very easy way of preventing that complication. And here we have another version of it. Again, just place the phaco tip, swing it around and push down ever so slightly, nice and gently and the iris will fall back and then the second instrument can be removed. You can see that the pupil is still a little bit peaked, but then a little bit of viscoelastic through the side port or BSS will easily correct that for you. And the iris prolapse can occur for multiple reasons. It could be that your incision is too big, it could be your second instrument catching the iris. It could be secondary to intraoperative floppy iris syndrome. It could be a hidden fragment that’s hiding underneath the iris, pushing it upwards. Sometimes when you’re flushing out the anterior chamber, you might suddenly see a small fragment reappear that has to be removed later on. Or, as you’re removing the second instrument if you stroke the eye with the instrument it collapses the side port. Do think about using fluid dynamics and the phaco probe to push the iris away very gently. Now whilst you’re waiting for your irrigation/aspiration instrument, and you’ve inserted phenylephrine to dilate the pupil, what could we do to protect the side port? Could you use hydration or would you use viscoelastic? Now, I’m aware that in many countries you may only have one viscoelastic vial to use. And once you’ve used it, you don’t have any more. Or you may have some on standby, but if the patient has to pay for their surgery it could work out more expensive. I don’t know whether that will influence your decision here. All we are trying to do is prevent the iris from prolapsing through the side port. What would the audience do? The majority of you, 68%, would use viscoelastic to put it back. I think that’s not a bad thing to do if you’ve got lots of viscoelastic. For me, I tend to use just a little bit of BSS because it’s easy to inject and I can hydrate the side port at the same time. The thing is, you have to remember to remember the basics. And here a little bit of air has been injected into the stroma and they’ve got surgical emphysema of the side port. Thankfully it doesn’t really matter because that air will slowly absorb over the next few hours. But when you’re supervising somebody remember to teach them the basics before they inject any fluid inside the eye, check the cannula and make sure there’s no air bubbles. To prevent main wound iris prolapse, remember to slow down when you’re removing the instruments. When you take out the instrument from the eye, don’t stroke the sclera or the conjunctiva because it collapses by pressing on the posterior lip. When you’re inserting an instrument, say you’re inserting the phaco in a shallow anterior chamber, and you don’t want to hit the iris as you insert the instrument, use a little bit of viscoelastic to push that iris away or deepen the AC. And you can do the same thing for the side port. You can put a little bit of extra viscoelastic in anticipation of when you’re going to insert the second instrument. Or if you wanted to, if it’s a shallow anterior chamber, and you can’t get the second instrument in without touching the iris, try using the phaco to push back the iris slightly and then insert the second instrument before you start removing the lens. If injecting, don’t release the pressure on the plunger. And if you need to use phenylephrine to expand the pupil at any stage of the operation, just go ahead and do it. If you’ve got a superior incision and you’ve had some iris prolapse, consider inserting a small air bubble at the end of the operation that will push the iris back and therefore prevent it from prolapsing as the eye is healing. And if you need to, always consider putting in a stitch. But I can’t remember the last time I’ve had to do that. If you do get iris prolapse, try not to poke the iris with the cannula. Because all you will do is make a hole in the iris and even more pigment will be released. You have to think of the mechanism of why iris is prolapsing. It’s either because the pressure inside the eye is so great it’s pushing everything outside of the eye. The first thing to do when that happens is actually decompress the side port to allow the eye to soften slightly. And then if you can’t sweep the iris back through the side port, try stroking the cornea using a Rycroft or whatever instrument you want, as long as it’s blunt, press on the center of the cornea and move towards your main incision. And if you do that two or three times very gently, the iris will sleep back through the main incision back into the eye. And then you won’t have any problems with it. One of the other things I’ve learned in the last 12 months is dealing with a small capsulorhexis. And again, this is all about being active or non active. And some things can be fun to do. So let’s have a little look at a capsulorhexis. This person was a little bit kyphotic, their chin was down and by the time the person I was supervising did the capsulorhexis, you can see that it’s quite small. But the operation went very, very nicely and we were able to remove the lens, remove all the soft lens material quite easily and then we decided we needed to cut that capsulorhexis with a pair of Vannas scissors and then make it bigger. A single cut has been made, the eye is filled up with viscoelastic, and the edge of the capsule is grabbed a further circular rhexis is made to make it bigger. And you can do this for cases like pseudoexfoliation to prevent phimosis. But you can see here that as it’s made bigger, there’s a lot of pronation of the wrist and that’s causing the wound to distort, causing corneal folds. And the surgeon has been instructed to try and go all the way around the capsulorhexis to make it bigger in a 360 degree fashion. And the question is, do you really need to enlarge the rhexis all the way around to prevent phimosis. And the answer is probably not. You probably just need to make it sufficiently big just to make sure it doesn’t phimose. The question is, is there an easier way to make the rhexis bigger? I’ll show you a different video, and they just complete that. Here’s a case, pseudoexfoliation, a Malyugen ring has been put in and the rhexis, not a bad size but we want to make it bigger because cases of pseudoexfoliation are at risk of phimosis and subluxation and dislocation. Instead of making one cut with a pair of Vannas, the idea is that you make two cuts. Then as you enlarge the capsulorhexis, it will join from one cut to the other and you won’t then have to pronate your wrist so much. And you can do the extension of the rhexis in the clockwise or anticlockwise, it’s entirely your choice. To make things more routine, we fill up viscoelastic but again, the person has left an air bubble in, doesn’t really matter because it’s not over the area where we want to see. The edge of the capsule is grabbed, folded over. And the idea is to keep that flap on a short tether. And you can see that one cut joins the other. And that’s probably enough to stop that eye from phimosing. But if you want it to, you could still see the edge of the capsule, it would be very easy then to put the Vannas back in and make a further cut. Remember if you’re doing it again and again, then do top off with viscoelastic. and here the rhexis is grabbed and simply it will join from one cut to the next cut that was made. There we go. It’s an easy way to enlarge a rhexis at the end of an operation. I often get asked about my technique of chopping. I’ve realized in the last 12 months that all of the people I’ve taught I’ve been teaching my technique incorrectly. And I haven’t been teaching them the way that I actually perform that surgery myself. I’ve put together some slides to try and teach it properly. This is a video of my technique and me operating. And my aim is to break the cataract up into at least eight pieces, if not ten. I’m going to let the video run and then we’re going to break down the technique according to Peyton’s four step approach to surgery which is show something without discussing it, break down the technique, ask the audience what the technique is which I can’t do, and then finally get you to perform that technique. And often when you watch surgery, things happen very, very quickly inside the eye that you can’t quite follow what the person is doing because the movements are very quick or very flowing that you can’t break it down. So let’s go through that now. And I will show this video again later. There are lots of different ways to chop and every technique is absolutely fine. And you can use whichever technique you like. You can still use divide and conquer, it is a beautiful technique. But some people want to use different techniques for different cases. The first thing is that you need to bury the tip of your phaco probe into the lens. And you’ll notice that the phaco probe is aiming a little bit to the left. And you need to gently push against the lens so that there is hardly any gap between the phaco probe and the lens material itself. You then apply a small amount of phaco energy to bury the tip inside that lens. And you’re angling the tip slightly down so that it goes into the denser nuclear material. You want to use the smallest amount of phaco energy constant, you don’t want to have a large amount of phaco because it will try and eat all of that material. And I tend to use it on my second phaco setting which is fragment removal setting. Once the tip is buried, the thing you need to remember is to not pull the phaco tip. You want to be able to hold the phaco tip steady and still without it coming out of that fragment. And then you stab the lens just in front and to the left of the phaco tip. And you can use a little bit of aspiration to hold the lens in place, but if you’re finding that you’re using a huge amount of aspiration, it’s because you are pulling the phaco tip and the lens material towards you. You don’t want to do that. You then simply crack the lens with the phaco moving to the right and the chopper moving to the left. Now it doesn’t matter if the split when you crack it is complete or incomplete. You just want to do the movement. The split is then completed by doing what I call a reverse crack where the phaco then moves to the left and the chopper moves to the right. Again you may find that the split is incomplete but that’s absolutely fine. You’ll notice at this stage that the chopper is on the right hand side of the fragment. And the phaco tip is withdrawn but the chopper stays where it is. And then the whole fragment is rotated. And as it is rotated, the chopper passes underneath the phaco tip so that it doesn’t hit it. The chopper is then withdrawn and the phaco moves forward and the whole process is repeated as many times as you can. What I do for myself and people I’m teaching, I try and use my hands as an example. There’s the chopper, there’s the phaco tip. You bury, you push the phaco close, bury it in, chopper, crack, reverse crack, rotate, move back, move forwards, repeat. That will then ensure that you understand the steps of easy chop. The problem that people have is that they try and pull the fragments. And if you pull the fragments all that happens is the phaco tip falls out of the lens material. And it doesn’t matter if that happens whilst you’re learning it because you just simply go back to sculpting, groove, groove, then crack in the normal way, rotate the lens and try again. This is a learning curve and initially it may be a little bit tricky but it will get easier and easier the more times you practice it. So what have I been teaching that’s been incorrect? At the bottom half of the screen you’ll see that the phaco tip is buried on the left hand side. Whereas at the top, the phaco tip is buried to the right. Previously I was always doing the bottom but I was teaching it to bury the tip at the top. But what the difference is is that the second instrument has to travel across the eye if you bury the tip at the right hand side. And then that makes it much harder for the instrument control. It’s much easier to have the phaco on the left hand side so that the chopper is very, very close by. Let’s demonstrate that again and I’ll talk you through it. Minor rotation, long edging to crack. Rotate, bury the tip, stab the lens, crack, reverse crack, rotate. Bury it again, stab, crack, reverse crack, rotate. Bury the tip, stab, crack, rotate. Bury the tip, stab, crack, rotate. Bury the tip, stab, reverse crack, crack, rotate. If you’re instructing somebody, you can simply say simple words on what you want them to do. And you’ll notice that the fragments are not being pulled into the center of the eye. And if you’re teaching somebody phaco, you can split the lens into eight or 10 pieces, remove the first fragment into the anterior chamber and then they can take over the phaco component and they can remove all of the fragments very easily as they are learning phaco control. Let’s see one of my beginners do this technique. They can do a divide and conquer but they’re learning chop. They’ve buried the tip, they’ve buried the chopper and now they’re cracking. But what’s missed out? They haven’t done the reverse crack. They’re just doing the normal crack again and again but the phaco tip is no longer buried. They still managed to crack it though, but they’re using a little bit more force. Let’s have a look at their second chop attempt on the same eye. Notice the lens is being pulled towards them but now they’re burying the tip. The chopper goes in, but notice that the phaco is on the right hand side of the eye and the chopper has to travel right the way across it, it’s a little bit harder and I never noticed this when I was teaching people. You can see that the fragment is almost broken there. But you can see that the flow of bury the tip, chop, crack, reverse crack, is not being performed. They are trying to, they’re not accepting the fact that the fragment may not crack and split completely and they want it to be a definite split. But you have to remember it doesn’t work all of the time and it’s okay to rotate the lens and try again. Bury the tip, chopper in, and crack. And the nice thing about this technique is that you do not have to place the chopper beyond the equator, you don’t have to put it beyond the capsulorhexis. So there’s very little risk of you actually stabbing the rhexis and causing the capsule to split. And you can use this for reasonably dense cataracts or even brunescent cataracts actually. That’s learner one. If we look at a second person, let’s get this video to work. This person is really pulling the fragments towards them. And that’s because they are not pushing the phaco tip into the lens material itself. You can see that lens trying to be pulled forward. What I did was I forced them to pause by putting water on the eye every time they buried the tip. That taught them to keep the phaco tip steady. There’s lots of ways that you can force yourself to try and learn how to keep the phaco tip still inside those fragments. Sometimes if the fragment becomes free, instead of rotating and cracking and chopping, you can simply free up a small piece and then you can extract that and remove it from the eye to create a little bit of space. That piece is just held onto, a little bit of aspiration and phaco and you can see that it’s going to be pulled into the anterior chamber and then it will just simply be removed and the process is repeated. Remember when you’re burying the tip, you’re using a small amount of phaco energy. You are not grooving. You’re not using foot to the floor because otherwise the phaco tip will go through the lens material. You need to just bury the tip. I’ll show you the first learner, who after a period of time, has learned that technique. And you can see the technique is a little bit more similar now to my technique. They’re just a little bit slower and that’s absolutely fine. The question is, is can this person split the lens into eight to 10 pieces now and if they can it means that they can now teach somebody else phaco because they can split the lens into small fragments and then they can teach a beginner how to learn phaco control. And it takes a little while to get to that inflection point where you’re happy with the surgery. And you can see that I’ve disassembled the lens and I’ve stopped the video on the right and my learner is still doing the technique very calmly, nice and steady. They’ve split the lens already into five or six pieces and they’re going to carry on doing that crack, reverse crack. And the flow is much better. The same sort of density as the first time, doesn’t make any difference. The video is a little bit blurred because they still need to learn microscope control. But that’s okay. Young people tend to accommodate. That last piece is grabbed and then pulled into the anterior chamber ready for removal. Great. The next thing I want to teach on is something about rhexis. And I’ve learned two things. Firstly, I’ve changed using a 30 gauge needle. The same needle I would use for intravitreal injections. Because the needle is much smaller and much finer it is much easier to create the flap. Stab, slide, come back, tent up, push, and turn. And then the flap is created very, very easily. If you are using a cystotome, that is absolutely fine. If you’re using a forceps to stab the capsule, that’s absolutely fine. But if you’re using a straight orange needle, try using a 30 gauge, you may find it easier. The next thing is that I often see people struggling to grab the edge of a flap with a pair of forceps and they have several attempts to do it. And you can see with a pair of forceps that when you close them you can apply equal force to both sides of the prongs. But if you think about it, you can actually apply pressure on one side to close the forceps from right to left or from left to right. And you can also move the forceps a little bit to keep it in that position. One side of the prong is always held still while the other one is moving. When we try and grab a flap during rhexis, we know that for a person doing a clockwise, sorry, an anticlockwise capsulorhexis, you want to move the tearing point to the left. The assumption is that when you grab the flap, you move your hand to the left. But if we think about this, what happens is as those forceps are closed the flap is folded downwards and pushed downwards so the the forceps miss grabbing the edge of the flap. And what should actually happen is that the forceps should close with the prong on the left moving to the right to grasp hold of the edge, then you move to the left hand side. Let’s have a little look at this video. The needle is creating the flap, it’s always blurry when you’re watching somebody because the young person always accommodates. But what I want you to watch is the prong movement. There we have the left prong and the right prong. As the forceps are inserted. Just think which way is the forceps moving, or which prong is being closed. And do they manage to grab that flap? So they’ve had three attempts so far. That right hand prong is moving to the left hand side of the eye and they can’t grab the flap. But eventually they manage to grab hold of it because they move the left hand back towards the right hand side. Let’s look at that in slow motion. Just look at the prongs. The right hand one moves, missed it. And again, right hand one moves, missed it. This time, right hand one moves, missed it. Try again, left hand one moves, they’ve grabbed it, oh sorry, that was the right hand one. Left hand moves to the right hand side of the eye, they’ve grabbed the flap and now they can carry on moving that around in a circle. The video is blurred but you should hopefully be able to see the way that the prongs are moving. Next time you see a beginner struggling, have a look at the way that they move their hands. This is the rhexis that I showed earlier. And I just want you to look at the prongs again as they grab the rhexis. Which one moves? The left one moved to the right hand side, grabs it in one go and then continues the movement to the left. Have a little look at the way that you grab the flap with your forceps and see which way you move for the initial movement. Great. It’s coming up to three o’clock. I’ll share one medical retina case and then I’ll answer some questions. I have a question for you, we have a color image and the OCT. I want to know whether you think that the color image, does it match the OCT findings? I’ll just let that play. Do you think that the color image has an artifact and the OCT is normal? Do you think that the color image is abnormal but the OCT doesn’t match the color pathology? Or do you think the color image is abnormal and the OCT definitely shows the pathology? Or are you not sure? Often when photographs are taken we can rely on OCT findings probably a little bit too much and you can look at images or look at the patient on the slit lamp and it doesn’t quite fit. Let’s see what people say. Okay. The color image has an artifact and the OCT is normal. Great. I completely agree with you. The color image is abnormal but the OCT looked normal. Okay. And the OCT doesn’t match it. Let’s have a little look at that and say why. Here we have the OCT and the scans are horizontal. What the color image shows are radiating horizontal dark and light lines at the level of the choroid. But because the scan is horizontal, it is missing the pathology. And what you want is not a horizontal scan, you want a vertical scan. And here you can see that the OCT now shows these lovely choroidal folds very, very easily. This person was coming to the clinic probably for about a year when everyone was saying we think they have choroidal folds but the OCT is normal. I looked at them clinically and went hang on, they do have choroidal folds, they need investigation. Just a very simple change in thinking can help you make the diagnosis and then help you investigate it. I’ll give you one case because this is a good case. This is a 69-year-old woman who attended as an emergency because she had hazy vision in her right eye. 6/12 vision. And you can see that the OCT shows a huge amount of subretinal fluid. On the vertical, you can see that this image shows a disturbance within the macula, extending superiorly. And the thing that you notice here is that the subretinal fluid, you cannot see the upper limit of it. And the differential in casualty, was that this person had a central serous retinopathy. And this person was referred to myself for an opinion. Normally this is a condition that is around the age of 40 or 45, more common in men than women. It can be found at any age and if it’s in an older age group it tends to be chronic. It’s usually self-limiting and the definition of a CSCR is a detachment of the neurosensory retina which this person has. But it shouldn’t be secondary to holes, tears, inflammation, or any other cause. They come into my clinic two months later. They still have subretinal fluid, the vision is still 6/12. Normal intraocular pressure, but I make the diagnosis when I check the intraocular pressure. And I made it at this sort of stage. The person has been dilated, they have a fairly oval pupil but that could be slightly misopen because of the drops. When you look at this fundus, they have this abnormality in the superior part of their macula with the subretinal fluid. The question is, have I made a fundal diagnosis by checking the IOP? Well, when I get people to have their IOPs checked, I always get them to look down before I then get them to look straight as I push the applanation tonometer head towards their cornea. And as soon as I did that, I saw this great big scleral lesion. And this is a ciliary body tumor. And if you look at the wide field image, they have a big tumor superiorly. And the OCT, courtesy of my colleague Ms. Johnson, shows this mass in that kind of ciliary body region. The person was referred and they needed an enucleation to treat this. Time for questions. I’m going to stop sharing and we’ll go to the question page. There are a few questions that were sent in previously. And there’s some questions on the board. Here we go. May I ask the name of the chopper that I use? Right, I must admit I just ask for a chopper. I know that there are lots of different types of chopper, Greens chopper, sharp pointy ones, I simply just ask for a chopper and I use whatever is given to me. I used to use a mushroom, but actually you can’t chop very easily with a mushroom. I just use what I have on the trolley, if I’m honest with you. I don’t even know the name of it, that’s how bad a surgeon I am. I wonder what references you recommend for beginners and supervisors. That’s a great question. A lot of problems occur when people are supervising because they don’t have the same language or instructions and they misunderstand each other. If you go back to the Cybersight talk I first gave, the first lecture, it talks a lot about the instructions and the terminology that I use and it’s very helpful to watch that. And when you have a new supervisor, sit down for 10 minutes beforehand and say, when I’m grooving, what do you call this? Which parts of the eye do you use clock hours, do you use degrees? And if you set that target it makes it much easier to understand. Everything I do in phaco has a term given to it like crack, reverse crack, rotate. I use all of those terms so that when I’m teaching I only use one or two words and the person understands what I want them to do. After how many complicated cataracts should we quit surgery? Ha ha. I think that’s an interesting question. We know that with simulation all surgeons should do a degree of simulation and that will help with their overall complication rate. We have either model eyes, animal eyes, you can get a piece of plastic and put it onto a cup and practice the rhexis, there are lots of different ways that you can do this. Secondly, the instruction that you have is very important. If I look at my trainee complication rate, in the first time in two years yesterday I had a PC rupture with my trainee. The first time in two years. If you are taught and supervised very carefully you can avoid major complications. But you also need to know how to manage the complications. Having a PC rupture is not a complete disaster, because if you do the vitrectomy very nicely and you can put in a sulcus implant, the patient will do very, very well. They’ll still get 6/9 vision and be able to see or drive very, very nicely. But it’s managing that complication that is the key element of it and not panicking when that happens. Question here. Do you think that binocular vision is indispensable for cataract surgery? Many years ago I’m sure that there were lots of ophthalmic surgeons that did not have true binocular vision. It is not tested in the UK as a requirement for entering training. If a surgeon is struggling with surgery, help and support is given and they may need a surgeon that is a very good trainer to help them and guide them through that learning process. But there are going to be surgeons that actually don’t enjoy surgery, they find it very, very stressful dealing with that or dealing with a complication. They go home and they worry and they worry, and I don’t think that’s good. We are doctors to help people and we want to enjoy the work that we do. You should find surgery fun and enjoyable and if you’re not, then really have a discussion with somebody about whether or not that surgery is for you. What was the cause of the choroidal folds in that case? That’s a great question. Most of the time choroidal folds are idiopathic. And you’ll never know why they have them. It could be associated with hypermetropia, or it could be due to something compressing the globe. It could be from thyroid eye disease, it could be from hypotony, it could be from inflammation. If I have a patient with bilateral choroidal folds that isn’t a hypermetrope, I will always do a CT scan of their head and orbit just to make sure that there is nothing else going on like a mass. Ideally you should do an ultrasound of the globe, just to make sure that there is no scleritis and make sure there is no T sign on the ultrasound probe because that’s very easy to miss. In this case it was completely idiopathic. What is the safe way to remove the nucleus because my complications are during nucleus removal. The first thing that I would say there is learning to remove the nucleus, there’s a lot of things going on you have to use your right hand, your left hand, your right foot, your left foot, you have to listen to the machine and you have to relax your shoulders, so there’s a lot of things going on. The way that I teach nucleus removal is that I will split the lens into six to eight pieces. I will remove the first fragment and then get my learner to learn how to phaco those small fragments. By doing that, they then don’t have to go deal with large fragments, they just have to learn foot control. Because that’s really, really important. You want just a little bit of phaco so that the pieces can move and they can get eaten by the phaco tip and you learn to do that on a variety of lenses. 20 cases. As you get better, you could leave the fragments, they can get bigger and bigger and bigger until eventually you deal with four fragments. Once you have the phaco control, then you can start doing your cracking and grooving because that will be much, much easier. Often mistakes happen because people chase fragments. and what they do is they put the phaco tip deep inside the eye to try and aspirate or grab a fragment. You need to remember the fragments need to be loose and disassembled and free to move. What I call, make a space. You need to make sure that a fragment isn’t coming to you, ignore it. Rotate the lens, try another fragment. If it’s not coming to you, something is stopping that fragment from coming out. It either isn’t split or another fragment is in the way, or your second instrument is in the way. That’s what I would say there. Just go slowly, don’t try and be a fast surgeon when you’re learning. It’s better to have an operation that takes 23, 27 minutes, 28 minutes, than it is to have a vitrectomy where you’re taking 40, 50 minutes when you’re a beginner because your supervisor will then really get annoyed if that happens again and again and again. If a PC rupture does occur, your supervisor shouldn’t shout at you. They should give you positive feedback first. You did a really nice rhexis, your hydrodissection was great, you did grooving great, you did splitting lens. When the PC rupture occurred, you inserted viscoelastic through the side port, pushed the vitreous back and I was able to take over. Then you can go through what actually went wrong and what things you need to do next time. I want to know if you do horizontal chopping? I always get a little bit confused, if I’m honest with you, with the terminology of vertical and horizontal chopping. If you look at some of the American surgeons, they will talk about all of these. I tend to just do easy chop because it’s very simple to do, it works beautifully well in a variety of lenses, and it’s very easy to teach somebody how to do it. You don’t break the capsule, you don’t have to go out into the periphery, if it doesn’t work you simply go back to a divide and conquer. Do you recommend clockwise or counterclockwise for the CCC? I’m right handed so I will always go counterclockwise for my rhexis. The reason is, if you go the other way you’ll end up pronating your wrist at a difficult moment and it’s difficult to do. As you get more experienced, you want to be able to go both directions. Because you never know, you might be teaching somebody who is left handed. In which case, if you have to take over, you have to be able to do it both ways. I would practice doing both for it. Tips for doing the perfect capsulorhexis? Firstly, try not to force yourself to do a perfect rhexis. If you go for perfection you will always, always be annoyed with yourself. Things to do are, take your time and learn not to take the rhexis flap too far. You don’t want to get stuck in the subincisional areas. And what people do is they grab the flap and keep going, keep going, keep going, and then when they let go and try and grab it again they get stuck. Try and let go where it’s easy to grab and then do that subincisional area in one go. And I think I talk about that in the first talk for Cybersight. So I would just have a little look at that. How much aspiration do I use for easy chop? That’s a great question. I try and use a little bit of aspiration when I’m cracking, sorry, when I bury the chopper and crack. But I don’t tend to use a lot because as you’re splitting the lens, if the material is not completely in the phaco tip then it can aspirate and you don’t want to do that. Secondly, if you’re using a lot of aspiration, it means that you are pulling the phaco tip backwards and it will fall out of the lens material. Force yourself to bury the tip and then leave it there, turn off the aspiration, and hold the phaco tip in the lens material for about two or three seconds. And see if you can just hold it there before you place the chopper. And that will teach you really, really good technique, especially when you want to do fragment extraction from the bag. Because it allows you to manipulate the fragments and moves them in the bag much easier. In the case of a hyperope with severe floppy iris, crowded eye, pushy eye, bolus of IV mannitol. You can use mannitol. In very short eyes 20 millimeters or less, I tend to give them acetazolamide 250 milligrams beforehand. For shallow eyes or previous angle closures, what I tend to do is after I create the capsulorhexis flap, I always fill up with viscoelastic after I’ve created the flap. Don’t try and do the rhexis and then get to a point where you think the rhexis is veering out and then try and top up with viscoelastic, because it’s too late. Do it right at the beginning and I do that with white cataracts as well. Then after I’ve done the hydrodissection, I will put a little bit of viscoelastic next to the iris near the side port and near the main wound so I can get my phaco probe in. And then I do what’s called a bird’s foot. I want to convert that shallow anterior chamber to a deep anterior chamber. Rather than just doing a single groove, I do a groove, then a V. And what that does is it takes the top layer of the lens material away and then all of the sudden the anterior chamber is lovely and deep. If you’re worried about the endothelium, you could always use a soft shell technique. There’s a question here that says, I got a PC rupture last week because I had the sharp end of the nucleus facing downwards. I’ve seen this as well. And what happens is that as you take out the pieces, a fragment can rotate and what people do is they try and grab that fragment and it either rotates with the sharp bit pointing down or it rotates so the sharp bit is pointing towards the capsular bag. You want to keep things simple. And the way that you remove the fragments is normally with the apex of the fragment towards the phaco tip. If it oscillates and turns around, rotate it so that the smooth edge is back in the bag, use your chopper just to keep it there, then bury the phaco tip into it, then pull that fragment out of the bag. What phaco settings should you use for a beginner? I think this is always a tricky one. It will depend on the machine and I would say that you need to use the settings that your trainer is using because he is teaching you and he will know what is best settings for that machine. Do you prefer continuous pulse or burst for teaching? I tend to use foot control. We use an Alcon machine in my hospital and it does have a certain amount of phaco energy. So I try and remove the fragments and if it’s oscillating it will use a lateral oscillation and it will go ch-ch-ch-ch-ch-ch as it’s removing the fragment. It just depends on your foot control on how much energy and whether you want to do a self burst you can just set it onto a pulse mode, that’s entirely up to you which works best for you. What’s the best way to go for a patient with IOL displacement and posterior capsular opacities? I think that’s always tricky. I must admit I haven’t had too many IOLs displaced. Thankfully I don’t get too many complications. Posterior capsular opacities, I presume you’re talking about PCO, if there’s a lot of plaque you can polish it at the time. If there’s a posterior polar, you just have to be careful because if you polish it, you may find that you tear the bag right at the end of the operation. It is better to see if you can visco dissect it, if it doesn’t come away, leave it alone, put the lens in, it’s much easier to do a YAG capsulotomy several months down from the operation and the person will have very good vision. There were a few more questions from the people previously. How do you prevent endothelial loss? The first thing is to look at the type of cataract, look at the endothelium and see if there’s any signs of endothelial loss to begin with, Fuch’s. If you need to use a soft shell technique, use it. Don’t be afraid to top up with dispersive viscoelastic as you’re removing the fragments. Don’t just think you can put it in once and leave it, it’s in the vial, it will go in the bin so you might as well keep topping up after it every few fragments, that makes it easier. When you’re phacoing, making sure you don’t see the mouth of your phaco tip. If you can, it means that the energy is going up towards the endothelium. Somebody asked me about soft cataracts. With soft cataracts you have a choice, you could either delineate the soft cataract as many times as you can to try and get a gold ring sign. And then use the phaco tip on as if it’s the irrigation/aspiration and just gently aspirate that lens. If you have a beginning, what I tend to do before they start the phaco is I would reduce the phaco energy from 55% power right the way down to say 35 or even 40%. That way even if they put their foot down accidentally, there’s less energy to use. Last question here was what can you practice capsulorhexis on at home? I think there’s lots of things that you can do at home. One is go through the steps in your mind, just like I did with easy chop. Break it down. Viscoelastic inside the eye, side to side motion as you enter the wound, where are you going to stab it? Is it in the center or to the left? Stab, slide, come back, lift up, push, turn, forceps. You need to know what you are doing before you actually do it in a real eye. If you’re trying to learn the technique completely as a beginner, it’s much harder to do. Try and get some sort of simulation. You can use plastic, if you’ve some flowers, they’re normally wrapped in a very thin piece of plastic. You can use that over a cup. You can take some instruments, cut it and use that. There are model eyes that you can get but they are very expensive. But I’m sure that in most countries you can get something that you can use as a simulation. Do you observe more complications with three piece IOLs compared to one piece, assuming operation was normal? In my hospital we tend to use a once piece lens. Three pieces, I was trained using three pieces and they’re absolutely fine. There’s just a technique of putting them in and dialing them in accordingly. As long as you know what you’re doing, and are shown how to do them, then you shouldn’t have any problems with either. It’s your choice. Posterior polar that you can’t hydrodissect? I think that what you have to do is inject the fluid before the rhexis edge. And then advance the cannula underneath the rhexis and inject very, very slowly. Then do it on the other side and then do what I call a sweep where you place the cannula underneath the rhexis. And mechanically, turn the cannula and then do it from the other side and inject a little bit. And then delineate. Because then you’ll find that it separates it really gently. You don’t want to do that hydrodissection quickly and then that should be fine. I’ve never really had a problem there. How do you manage frequent occlusion in a phaco machine in a hard cataract? I have two settings on my machine. Normal and dense. I never have to think about which settings I’m using if I find on the first groove it doesn’t groove very easily, I simply say dense setting. It’s much easier to do that with the modern machines. Why mess around asking for the power to go up, just have two different settings. I think, because we’re coming up to 25 past, we’ll stop there. Thank you very much.